Criminal Code (R.S.C., 1985, c. C-46)

Canada,

Province of ,

(territorial division).

To the peace officers in the (territorial division) and to the keeper of the (prison) at :

This warrant is issued for the committal of (name of person), of , born on (date of birth), referred to in this warrant as the accused.

Because the accused has been charged with (set out briefly the offence in respect of which the accused is charged);

And because (check those that are applicable):

• □ (a) the prosecutor has shown cause why the detention of the accused in custody is justified [515(5)];

• □ (b) a release order has been issued but the accused has not yet complied with the conditions of the order [519(1), 520(9), 521(10), 524(8), 525(6)];Footnote ^*

• □ (c) the application by the prosecutor for a review of the release order has been allowed and that release order has been vacated, and the prosecutor has shown cause why the detention of the accused in custody is justified [521];

• □ (d) the accused has contravened or was about to contravene a (summons or appearance notice or undertaking or release order) and it was cancelled, and the detention of the accused in custody is justified [515(10), 523.1(3), 524(3) and (4)];

• □ (e) there are reasonable grounds to believe that the accused has committed an indictable offence after having become subject to the (summons or appearance notice or undertaking or release order) and the detention of the accused in custody is justified [515(10), 524(3) and (4)];

• □ (f) (if none of the above applies, reproduce the provisions of the statute that authorize this warrant).

Therefore, you are ordered, in Her Majesty’s name, to arrest the accused and convey them safely to the (prison) at , and there deliver them to its keeper, with the following order:

You are ordered to receive the accused in your custody in this prison and keep them safely there until they are delivered by due course of law.

Signed on (date), at (place).

(Signature of judge, justice or clerk of the court)

(Name of the judge or justice who has issued this warrant)

• Return to footnote ^*If the person having custody of the accused is authorized under paragraph 519(1)(b) of the Criminal Code to release the accused if they comply with a release order, endorse the authorization on this warrant and attach a copy of the order.